Provider Demographics
NPI:1275787152
Name:CLARK, MERRY LACY (MS, CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:MERRY
Middle Name:LACY
Last Name:CLARK
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4025 OVERLOOK POINT CT
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70817-1620
Mailing Address - Country:US
Mailing Address - Phone:432-413-8386
Mailing Address - Fax:
Practice Address - Street 1:5422 SUPERIOR DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-6063
Practice Address - Country:US
Practice Address - Phone:225-802-7748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-05
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7028235Z00000X
PASL009003235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist